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SITE IDENTIFICATION FORM <br /> (Atueh fiddidaml deeeripdon or explanation to needed.) <br /> Initial LD.6�0: &S . Follow-up Investigation (YIN): <br /> SrM MFORMATION <br /> Site Name: LA-re%eje..)c� Lrv'zeszea — s'L7I :1 con <br /> AKA: s aac- .3 <br /> SWIS ': _ ...___County:.sAs).-" out-)Parcel #(s): •2sI.- info - <br /> os <br /> �Location: s <br /> lreO aua or�Map w1ulPowninipmaor,AM seetwnT3 Trareel MAP.) <br /> Land Owner(s): �S ,�4�e�-xr,�,.rro� .✓+Secs ' u• S r�✓c"Ar <br /> Address: <br /> City: ._State: Zip: Phone: <br /> Types of Waste: •Inort Res., Com., Indust., Haa. Liquid <br /> Site.`Type: egal Dumping, Landfill, Burn Dum ,-7�& Treatment Unit <br /> Disposal Area (Aero)!- 'N SWFP Date: WDR Num er: <br /> Dates of Operations: .-e - f g'o Closure Approved By: <br /> LAND USE ON OR WrrEUN 1000 FT 1 MILE OF WASTE BOUNDARY <br /> Rural: o <br /> Residential: es o ; <br /> Commercial: Y es N <br /> Industrial: <br /> Environmental Sensitive: Yes No <br /> Water Supply Wells: NO Yes No _ <br /> Surface Water Bodies: --Yeses es o <br /> Inhabitable Structures: es o <br /> Enclosed Structures: Yes . es <br /> Planned Improvements: Yes No Yea No _ <br /> OESERVATIONS <br /> Date of Field Visit: 13 Sig. Change Since Last Visit? (YnC�� <br /> Surface Condition: ego.I <br /> Landfill On: <br /> Leachate: <br /> Other:_ <br /> RECOMMENDATION <br /> Emergency Response: <br /> Other (e.=. man sWe illegl duVidl that war uta mwvd): - - <br /> Reassess Site? (Y/NINA): No Further Action? (D Priority Y/N): <br /> Priority for Site A it ed/Law): <br /> . . Prepared $y: Date: 4 �3 <br /> CIWUM Approval: ch Compliance <br /> Cr#MB Cloture and Retnedladon Branch(Rev.3 /93) <br /> Board Approved(4m/93) <br />